Beyond Biomedicine: Relationships and Care in Tuberculosis Prevention

With attention to the experiences, agency, and rights of tuberculosis (TB) patients, this symposium on TB and ethics brings together a range of different voices from the social sciences and humanities. To develop fresh insights and new approaches to TB care and prevention, it is important to incorporate diverse perspectives from outside the strictly biomedical model. In the articles presented in this issue of the Journal of Bioethical Inquiry, clinical experience is married with historical and cultural context, ethical concerns are brought to bear on global health, and structural analyses shed light upon the lived experience of people living with TB. The relational and reciprocal dimensions of care feature strongly in these discussions, which serve as a poignant reminder that behind each of the yearly deaths from TB is a deeply personal story. No single discipline holds a monopoly on how to care for each of these people, but strong cases are made for support from mental health and social workers in addressing the kaleidoscope of needs in TB prevention. As the World Health Organization moves towards the goal of eliminating TB globally by 2050, attending to the needs of TB patients serves global interests to lower disease burden and to develop better integrated communities worldwide.     

Monitoring Intervention Coverage in the Context of Universal Health Coverage

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors'' Summary

Summary Points

• Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health.
• Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage.
• Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal.
• Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people''s expectations, the indicator sets will not be the same everywhere.
• Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure.
• A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights.
• Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention.
• Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations.
• The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC.
• It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers.

This paper is part of the PLOS Universal Health Coverage Collection.

     

Equity-Oriented Monitoring in the Context of Universal Health Coverage

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

• The equitable realization of universal health coverage requires an equity-oriented approach to monitoring; equity advocates should be unified in proposing a technically sound platform for monitoring that is easy to understand and communicate.
• Global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence, in addition to sex), adopt a gap or whole spectrum approach, and conceptualize economic-related measures using quintiles.
• Both absolute and relative measures of inequality as well as disaggregated data should be reported, and national averages should be presented alongside inequality monitoring.
• Targets for global monitoring of health inequalities should be based on proportional reduction of absolute inequality.
• Countries can develop capacity for health inequality monitoring by strengthening health information systems for data collection, analysis, reporting, and dissemination.

     

Effective Coverage: A Metric for Monitoring Universal Health Coverage

A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric — need, use, and quality — using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

• Effective coverage unites intervention need, use, and quality into a simple but data-rich metric, reflecting the core components of UHC.
• Effective coverage can be applied to understand the health gains delivered by interventions at a range of levels, from individual benefits to national impact.
• Effective coverage can be measured and used across resource settings. Lower-income countries can harness data from existing survey data to feed into effective coverage estimations.
• The broader use of effective coverage remains hindered by the availability and quality of health data, especially at subnational levels.

     

Latent Tuberculosis Infection and Occupational Protection among Health Care Workers in Two Types of Public Hospitals in China

Objective

To determine the impact factors of latent tuberculosis infection (LTBI) and the knowledge of TB prevention and treatment policy among health care workers (HCWs) in different types of hospitals and explore the strategies for improving TB prevention and control in medical institutions in China.

Methods

A cross-sectional study was carried out to evaluate the risk of TB infection and personnel occupational protection among HCWs who directly engage in medical duties in one of two public hospitals. Each potential participant completed a structured questionnaire and performed a tuberculin skin test (TST). Factors associated with LTBI were identified by logistic regression analysis.

Results

Seven hundred twelve HCWs completed questionnaires and 74.3% (n = 529) took the TST or had previous positive results. The TST-positive prevalence was 58.0% (n = 127) in the infectious disease hospital and 33.9% (n = 105) in the non-TB hospital. The duration of employment in the healthcare profession (6–10 years vs. ≤5 years [OR = 1.89; 95% CI = 1.10, 3.25] and>10 vs. ≤5[OR = 1.80; 95% CI = 1.20, 2.68]), type of hospital (OR = 2.40; 95% CI = 1.59, 3.62), and ever-employment in a HIV clinic or ward (OR = 1.87; 95% CI = 1.08, 3.26)were significantly associated with LTBI. The main reasons for an unwillingness to accept TST were previous positive TST results (70.2%) and concerns about skin reaction (31.9%).

Conclusion

A high prevalence of TB infections was observed among HCWs working in high-risk settings and with long professional experiences in Henan Province in China. Comprehensive guidelines should be developed for different types of medical institutions to reduce TB transmission and ensure the health of HCWs.     

Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

This paper is part of the PLOS Universal Health Coverage Collection.

Key Summary Points

• Health payments are a heavy financial burden for millions around the world. Financial risk protection is concerned with safeguarding people against the financial hardship associated with paying for health services.
• Two commonly applied concepts capture the lack of financial risk protection. The first, catastrophic health expenditure, occurs when a household''s out-of-pocket (OOP) payments are so high relative to its available resources that the household foregoes the consumption of other necessary goods and services. The second concept, impoverishment, occurs when OOP payments push households below or further below the poverty line, a threshold under which even the most basic standard of living is not ensured.
• Headcount indicators, which measure the number of people affected, alone do not give the full picture of the problem. Additional measures of the intensity of financial hardship provide useful insights into the nature of OOP payments in different settings.
• Robust monitoring of financial risk protection requires reliable household expenditure surveys ideally conducted every 2 to 5 years.

     

The Role of Social Contexts in Adolescence: Context Protection and Context Risk in the United States and China

A theoretical framework about protective factors (models protection, controls protection, support protection) and risk factors (models risk, opportunity risk, vulnerability risk) was employed to articulate the content of 4 key contexts of adolescent life—family, peers, school, and neighborhood—in a cross-national study of problem behavior among 7th-, 8th-, and 9th-grade adolescents in the United States (n = 1,596) and the People's Republic of China (n = 1,739). Results were very similar in both samples and across genders. Measures of protection and risk in each of the 4 contexts uniquely contributed to the account of problem behavior involvement even when individual-level measures of protection and risk were controlled. Context protection was also shown to moderate individual-level risk and protection in 1 context moderated risk within that context and in other contexts. Controls protection—protection provided by rules, regulations, and expected sanctions for transgression from adults and peers—was the most important measure of context protection in all but 1 context. The family and peer contexts were the most influential in the U.S. sample, and the peer and school contexts were the most influential in the Chinese sample; the neighborhood context was least influential in both samples.     

Beyond the Biomedical: Community Resources for Mental Health Care in Rural Ethiopia

BackgroundThe focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources.MethodWe employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered.ResultsThe district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities.DiscussionThe plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention.